Social and structural HIV prevention in alcohol-serving establishments: review of international interventions across populations.

Alcohol use is associated with risks for sexually transmitted infections (STIs), including HIV/AIDS. People meet new sex partners at bars and other places where alcohol is served, and drinking venues facilitate STI transmission through sexual relationships within closely knit sexual networks. This paper reviews HIV prevention interventions conducted in bars, taverns, and informal drinking venues. Interventions designed to reduce HIV risk by altering the social interactions within drinking environments have demonstrated mixed results. Specifically, venue-based social influence models have reduced community-level risk in U.S. gay bars, but these effects have not generalized to gay bars elsewhere or to other populations. Few interventions have sought to alter the structural and physical environments of drinking places for HIV prevention. Uncontrolled program evaluations have reported promising approaches to bar-based structural interventions with gay men and female sex workers. Finally, a small number of studies have examined multilevel approaches that simultaneously intervene at both social and structural levels with encouraging results. Multilevel interventions that take environmental factors into account are needed to guide future HIV prevention efforts delivered within alcohol-serving establishments.

A lcohol use is among the most reliable predictors of sexual risk behavior across popula tions at high risk for human immun odeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS). Associations between alcohol use and sexual risks are observed regardless of whether alcohol use is measured in terms of global patterns of drinking, or within situations where drinking occurs, or at the level of sexual events (Weinhardt and Carey 2001). Alcohol elevates sexual risks through multiple channels, including the psychological effects of intoxication on decisionmak ing, inhibition of protective actions, interactions between drinking and risk taking personality characteristics, and perceived expectations regarding the effects of alcohol use on risktaking and sexual experiences (Cook and Clark 2005). The association between drinking and sexual risk behaviors has led to interventions that seek to reduce both alcohol use and sexually risky behaviors (Palepu et al. 2005). For example, an HIV risk reduction inter vention for innercity AfricanAmerican men reduced alcohol use in sexual contexts by 85 percent from baseline (Kalichman et al. 1999). In a similar study of oneonone risk reduction counseling in South Africa, researchers reported a 59 percent reduction in alcohol use in sexual contexts 3 months following the intervention (Kalichman et al. 2007). However, the intervention effects on sexrelated alcohol use decreased within 6 months to a 43 percent reduction from baseline. This shortlived effect is likely the result of individuals returning to unchanged highrisk environments that support riskrelated alcohol use (Kincaid 2004), suggesting the need for interventions to alter risk factors within alcoholserving environments.

HIV Prevention in AlcoholServing Establishments
This article examines the alcohol serving venues that intersect with HIV transmission risks and offer potential environments for HIV prevention. Venues of greatest interest are those that sell alcohol for onsite consump tion and serve as a point of social interaction. Multiple types of drinking establishments fit these criteria across cultures, including neighborhood bars, dance clubs, karaoke bars, taverns, wine shops, and informal lounges. In addition to describing the intersection of drinking places with HIV/AIDS risks, this article reviews the literature on HIV prevention interventions based in alcohol venues. Venuebased interventions are defined as strategies designed to alter the social and/or physical environment to promote protective action and reduce risk. Therefore, this article does not include interventions that target drinkers or those that are delivered outside of drinking places. The outcomes from completed venuebased intervention trials point to gaps in the existing lit erature and suggest future directions for HIV prevention efforts based in alcoholserving venues.

AlcoholServing Establishments and HIV Transmission Risks
The contextual factors within which alcohol and sexual behaviors intersect are critical to our understanding of how alcohol influences HIV risks. The environments of drinking establishments are multifaceted and serve multiple functions, including being a place for recreation, fostering socially sanctioned drinking, facilitating social relationships, and providing opportunities to meet sex partners. The subsequent sections review selected studies that describe sexual risks for HIV incurred within drinking places. These studies are sum marized in Table 1.

Studies of Gay Men
Early studies of HIV risks in alcohol serving establishments were focused on gay bars, primarily in the United States and Europe. Across studies, approxi mately one in three men who have sex with men sampled from gay bars and clubs reported engaging in unprotected anal intercourse, the highest risk behav ior for HIV transmission. Nardone and colleagues (2001), for example, found that onethird of men who go to gay bars in London and Edinburgh engaged in unprotected anal sex, and only half of the men had been tested for HIV. A study in California showed that one in three men who visit gay clubs and bars reported five or more sex partners in the past year (Xia et al. 2006). Men who socialized at gay bars also demon strated higher risk for HIV infection than gay men who did not go to bars, although men who drank at bars were at lower risk than men who attended sexfocused "circuit" parties. Another study showed that men who meet sex partners at gay bars may not differ sig nificantly from men who meet partners at other open gay venues, such as bathhouses, private sex parties, gyms, and the Internet (Grov et al. 2007). Although behaviors across gay commu nity venues may not differ, the preva lence of disease does vary. In China, for example, HIV (0.8 percent) and syphilis (2.4 percent) prevalence in gay bars is substantially lower than in gay saunas (3.6 percent and 20.7 percent, respectively) (Hong et al. 2009). From an HIV prevention perspective, gay bars may therefore be primarily social venues where sex partners meet and drinking may merely be a contextual rather than causal factor.

Other HighRisk Populations
Commercial sex workers represent a risk population that also is frequently accessed in drinking places. Female sex workers in Malawi, for example, who drink and contract a sexually transmit ted infection (STI) are less likely to use condoms than their counterparts who also contract STIs but do not drink (Zachariah et al. 2003). Women who socialize in drinking places, whether involved in sex work or not, demon strate a high risk for HIV infection (Kapiga et al. 2002;Singh et al. 2009). Meeting sex partners in drinking places increases the likelihood of sex after drink ing and reduces condom use (Mataure et al. 2002;Sivaram et al. 2008).

Analyzing the Overlap of Drinking Venues and SexPartner Meeting Places
Concurrency of sex partners within and outside of drinking places is a significant facet of HIV/AIDS in southern Africa (Carter et al. 2007;Mah and Halperin 2008) and is facilitated by the sexual networks within drinking establishments. Sex partners often meet at informal alcoholserving establishments that are common throughout southern Africa, such as private homes where alcoholic beverages are sold and served (Morojele et al. 2006;Weir et al. 2003). For example, one study (Kalichman et al. 2008) that surveyed men and women recruited from informal local township bars (e.g., shebeens) in South Africa found that more than one in four drinkers reported having met sex partners at their local shebeen. People who meet sex partners in drinking venues report greater numbers of recent sex partners and higher rates of unprotected inter course compared with people who did not meet partners in drinking places. Only half of those surveyed had been tested for HIV in a community in South Africa where one in five people are HIV infected (Shisana et al. 2005). These patterns of risk create urgency for HIV prevention in drinking venues. Using a welldeveloped system for rapid community assessments, Weir and colleagues (2003) mapped the linkages among places where people meet new sex partners and places where people drink alcohol. Studies that have used Weir's PLACE methodology show a consistent overlap among drinking behaviors and sexual risks in alcoholserving venues (Figueroa et al. 2007;Khan et al. 2008). For example, in Zimbabwe, 47 percent of women ages 15-19 years surveyed at night clubs and other drinking places had two or more sex partners in a 1year period compared with less than 5 percent of young women surveyed outside of drinking places (Singh et al. 2009). In South Africa, more than 85 percent of the places where people meet sex partners are alcoholserving venues (Weir et al. 2003).
The overlap between drinking places and venues where people meet sex partners was observed in both urban and rural areas. Across three cities in South Africa, between 78 percent and 87 percent of new sex partners met at shebeens. As many as half of the people who drink at shebeens report having had two or more sex partners in the previous 2 weeks, and more than half of men and one in five women who have met partners in shebeens have had sex on the premises (Kalichman et al. 2008). Not surprisingly, infor mal alcoholserving establishments rarely display HIV prevention mes sages or have condoms available for their customers (Figueroa et al. 2007;Weir et al. 2003).

Homes Where Alcohol Is Sold
Alcohol also is often sold from lounges in people's homes that double as small alcoholserving businesses. People who live in alcoholserving home businesses are at increased risk for HIV/AIDS. In Ugandan villages, for example, only 4 percent of people live in homes that serve alcohol, but the HIV prevalence in these homes is 15 percent, nearly double that of the surrounding com munity (Mbulaiteye et al. 2000).

Beer Halls
HIV risks also are observed in larger drinking venues, such as taverns and beer halls. Basset and colleagues (1996) reported that the HIV prevalence in Zimbabwean beer halls (i.e., large social venues that primarily serve men) is as much as twice that of the general Zimbabwe population. Sexual mixing patterns within beer halls facilitate HIV transmission, especially when other STIs are prevalent. For example, 60 percent of men and 40 percent of women who have multiple sex partners in Zimbabwe drink at beer halls (Lewis et al. 2005). Fritz and colleagues (2002) found similar behaviors in these venues and showed that HIV prevalence increases with greater frequency of drinking at beer halls.

Drinking Venue Employees
Employees as well as patrons of alcohol serving establishments are at higher risk for HIV infection. For example, men who work in Tanzanian bars and hotels who drink at least once a week are sig nificantly more likely to have herpes simplex virus infection, a known marker for HIV transmission risk, than other men surveyed at the same places who do not drink (Kapiga et al. 2002(Kapiga et al. , 2003. Women working in food and recreational businesses near southern African gold mines who drink are significantly more likely to have HIV infection than other women who drink in the communities that surround the mines but do not work in drinking venues (Clift et al. 2003).

Social and Sexual Networks
Higher rates of unprotected sex and STIs in contexts with high HIV preva lence create highly favorable circum stances for HIV transmission. HIV can rapidly spread within drinking venues that have tightly knit social and sexual networks which foster overlapping sexual mixing patterns. Alcohol serving establishments amplify HIV transmission risks by providing a place where sex encounters occur with rapid turnover of partners . Alcohol establishments are often themselves sex venues, where back rooms, back corners, and adjacent buildings or shacks offer locations for sex (Morojele et al. 2006). Beyond the social interactions that naturally occur in drinking places, the use of alcohol itself and its association with sexual risk behaviors makes these environments compelling venues for HIV risk reduc tion. The social and physical structures of alcohol drinking places therefore cre ate opportunities for communitybased HIV prevention interventions.

Alcohol Venue-Based HIV Prevention
A review of the literature on HIV interventions delivered within alcohol serving establishments yielded studies including randomized trials, quasi experimental studies (i.e., interventions in which the intervention groups and control groups were not randomized), and public health evaluations. The interventions evaluated in these studies (summarized in  (3) targeting both social and structural levels.

Social Influence Interventions
The majority of alcohol venue-based interventions target social environ ments to influence behavior. Such interventions aim to change the per ception that a particular behavior is socially acceptable (i.e., alter the per ceived social norms) and influence the interactions of people in the environ ment to shape and sustain protective social norms. Of nine trials identified, five focused on social influences for HIV prevention within drinking venues. Four interventions explicitly tested the popular opinion leader (POL) model (Kelly et al. 1997), and one evaluated a peerled intervention that approximated the central features of the POL model. The POL model identifies, trains, and motivates key communitydefined opinion leaders to act as agents of change by shifting social norms and thereby behaviors toward safer practices. The POL intervention is grounded in diffusion of innovation theory (Rogers 2003), which specifies that trends and inno vations are initiated by a relatively small segment of a population that acts as natural opinion leaders within environmentally or geographically demarcated populations. Innovations that are adopted, modeled, and endorsed by opinion leaders diffuse across social gradients throughout a population. Opinion leaders are trained in inter personal communication skills to enhance their sense of selfefficacy for acting as agents of change. Although generalized to other settings, the POL model was designed for use in drink ing places in small cities, where bars may offer the only outlet for gay men to socialize.
The POL intervention requires a small cadre of trusted, wellliked people who frequent the bar to be trained to initiate conversations and endorse safer sex practices. The active ingredi ent in the intervention is therefore informal casual conversations with peers, rather than formal education. Using conversations in natural set tings as the basis for delivering the intervention is the most compelling feature of the POL model. In these conversations, POLs can correct mis information; discuss the importance of HIV in the community; talk with network members about strategies to reduce risk, such as keeping condoms nearby; avoiding sex when intoxicat ed; and resisting unsafe sex. The intervention uses environmental prompts to serve as conversation starters, such as posters or tshirts with messages and logos. The interven tion core elements are (1) identifying and enlisting the support of popular and wellliked opinion leaders to take on riskreduction advocacy roles, (2) training cadres of opinion leaders to disseminate riskreduction endorsement The POL model intervention demonstrated 15 percent to 24 percent reductions in USI across all three cities. Similar outcomes occurred for numbers of sex partners and months postintervention.
increases in condom use during anal sex.
messages within their own social net works, and (3) supporting and rein forcing successive waves of opinion leaders to help shape social norms to encourage safer sex (Kelly 2004).

POL Studies Set in Small U.S.
Cities. Kelly and colleagues (1992) reported significant reductions in high risk sexual practices in smaller cities in the southern United States resulting from the POL intervention. The study used a quasiexperimental design with multiple baselines and staggered inter vention implementation. The first city to receive the POL intervention had two baselines and three 3month (9 months)interval postintervention implementation followups. Two addi tional cities implemented the interven tion after four baselines, with one city having two (6 months) and the other having one (3 months) postinterven tion followup. The pattern of results was consistent across the three cities: the POL intervention demonstrated reductions in men reporting multiple sex partners, unprotected insertive and receptive anal sex, and increased con dom use. The magnitude of change was significant, with up to 29 percent reductions from baseline levels. These behavior changes were bolstered by theoretically predicted changes in perceived social norms supportive of safer sex. Following the quasiexperimental study, Kelly and colleagues (1997) conducted an experimental test of the communitylevel POL intervention with eight matched pairs of smaller U.S. cities randomized to either receive the POL program or a comparison intervention that placed general HIV prevention education materials and condoms in the bars. The intervention implementation in half of the pairs of cities was systematically confounded with changes in season, possibly play ing havoc with the intervention implementation and assessments. The outcomes were therefore based on the remaining four pairs of cities. The findings mostly replicate the behavior changes observed in the earlier quasi experimental study, demonstrating 30 percent reductions in unprotected anal intercourse and 50 percent increases in condom use.

POL Study Set in New York City.
A study that implemented the POL model in New York City successfully replicated Kelly and colleagues' (1992) quasiexperimental trial (Miller et al. 1998(Miller et al. , 2003 among an extremely high risk group of male sex workers (i.e., hustlers). The adapted intervention demonstrated significant reductions in paid sex encounters and unprotected anal sex in paid sexual relations. In addition, moderator analyses showed that White and Latino men reduced their frequency of unpaid unprotected anal intercourse in response to the intervention, with no such reduction observed among Black men. This pattern of results was similar to that observed by Kelly and colleagues (1992), although with a somewhat smaller effect size.

POL With Community Interventions.
As part of a larger multicountry trial (National Institute of Mental Health [NIMH] 2008), researchers adapted the POL intervention to include additional elements of community mobilization derived from non-barbased communitylevel HIV prevention interventions (Kegeles et al. 1996). The adapted version was called the community-POL intervention, or C-POL. Researchers conducted the C-POL intervention in five countries, and in one country the implementa tion occurred in alcoholserving estab lishments. Specifically, the intervention was delivered at wine shops in slums of Chennai, India. Wine shops serve mostly beer and distilled alcohol as well as light food and have bars attached to them where patrons can sit and social ize. Such shops primarily serve men, although women frequently meet men outside or near the wine shops. A cluster of wine shops served as the defined intervention venue. The intervention group demonstrated substantial reduc tions in unprotected sex behaviors and reductions in STIs over the 2year observation period (NIMH Collaborative HIV/STD Prevention Trial 2008). However, similar reductions in risk and disease were observed in wine shops that served as controls, where only nontailored prevention messages were delivered. Specifically, wine shops exposed to the C-POL intervention had an STI incidence of 7 percent compared with 8 percent in the nonin tervention wine shops. Therefore, results of the C-POL intervention on wine shop patrons in India did not demonstrate significant effects on HIV transmission risk behaviors or on biologically assessed STIs. PeerLed Intervention. Fritz and col leagues (2009) implemented a social influence intervention that targeted men who socialize and drink in Zimbabwean beer halls. The intervention used a peerled education model that empha sized men talking with each other about HIV/AIDS prevention. Men volun teered to attend a 3day training to learn about HIV and how they can help their friends avoid HIV infection. The training included elements of information/education, motivational enhancement, and behavioral skills training for HIV risk reduction. Men who became "peer educators" agreed to volunteer and deliver prevention mes sages for 15 months posttraining. Like the POL/C-POL model, this interven tion was aimed at diffusing prevention strategies and messages throughout the beer hall to change social norms and behavior. Twelve beer halls were ran domly assigned to receive either the peer influence intervention or a stan dard message and access to condoms. The intervention failed to demonstrate any significant effects on behavioral risk indicators, including unprotected sex acts within and across specific part ner types, condom use, and numbers of partners. For example, men in the beer hall intervention sites reduced their unprotected sex by 11.8 episodes com pared with a reduction of 15 episodes among men in the control venues. The reductions were both significant but not significantly different from each other. Similarly, men in the interven tion beer halls reported an average of five episodes of unprotected intercourse with nonwife partners, as did the men in the control beer halls.

Structural Interventions
Interventions that aim to influence behavior through changes in law, policy, and the physical environment generally are referred to as structural interventions (Blankenship et al. 2000). In HIV prevention, examples of structural interventions include mandatory HIV testing for sex workers, closing of public sex environments, and legal needle and syringe exchange programs. Structural interventions also can include improved services that are meant to avert HIV transmission, such as enhanced STI detection and treatment and improved HIV prevention services (Bauermeister et al. 2008). Only two studies have reported on the use of structural approaches to HIV preven tion in alcoholserving establishments. Both studies were conducted as public health program evaluations that did not include comparison conditions. Rou and colleagues (2007) imple mented strategies to enhance HIV/STI education and diagnostic and treat ment services for female sex workers in bars, massage parlors, dance halls, and beauty parlors in two provinces in China. The intervention included active out reach to women in the venues as well as condom promotion campaigns.
Over 1 year of observation, the program showed significant improvements in HIV prevention knowledge, reductions in unprotected sex, and increased con dom use among women across venues. Prevalence of incident STIs dropped dramatically during the study period.
In a similar approach taken with men who have sex with men in New York City, Blank and colleagues (2005) reported the effects of the "hot shot" public health program. Aimed at men in gay bars, the intervention offered STI screening and diagnostic and treatment services in alcohol venues. The program reached over 1,600 men in six clubs and three communi tybased organizations and delivered health services to between 12 percent and 44 percent of event attendees. The program was deemed successful in terms of its implementation and detection of new cases of STIs and HIV. However, changes in behavior or in disease outcomes were not reported.

Combining Social Influence and Structural Interventions.
A potentially powerful approach to HIV prevention in alcoholserving establishments is the combination of both social influence and structural interventions. These multilevel models attempt to simulta neously shift social norms to reinforce protective behaviors as well as enhance services and change policies toward HIV prevention. Two studies reported the effects of multilevel social and structural interventions delivered in drinking places. Flowers and colleagues (2002) tested the Gay Men's Task Force intervention in Glasgow, Scotland. This intervention had three major compo nents, one social influence and two structural, each of which had been shown effective in the past and com bined for the first time. The interven tion included peerled sexual health promotion conducted in five gay bars by 42 peer educators over a 9month period. Peer educators, modeled after opinion leaders in the POL interven tion, received 2 days of training focused on communication skills for promoting safer sex messages. A second component of the intervention estab lished enhanced STI and sexual health services for gay men as well as a free sexual health hotline service. Results from the twocity quasiexperimental trial demonstrated a significant effect for engaging men in STI services, as evidenced by increased hepatitis B vac cination and HIV testing. Among men who had conversations with peer edu cators, 49 percent had contemplated and 26 percent reported making changes in their sexual behaviors. However, there was no evidence of community wide sexual behavior changes resulting from the intervention (Hart et al. 2004).
The second multilevel intervention targeted women sex workers in bars, discos, and night clubs in the Philippines (Morisky et al. 2006). The social influence intervention component was grounded in peer counseling. Female sex workers were enlisted and trained in HIV risk education and prevention actions, focusing on condom use and sexual negotiation skills. The structural component of the intervention enlisted the managers of the drinking places to attend HIV education sessions. The managers were trained to implement a continuum of HIV prevention policies and practices. The training focused on promoting employee health, with specific emphasis on the diagnosis and treatment of STIs. The quasiexperimental study used cities as the unit of randomization, with four cities randomized to four condi tions. One site received the peer counseling intervention, one site received the structural manager inter vention, a third site received both the peerinfluence and manager compo nents (multilevel condition), and the fourth condition received neither component. Results showed positive effects for both the individual peer counseling and manager components. However, the combination of peer counseling and manager training demonstrated the greatest impact on condom attitudes, venue policies favoring condom use, and reductions in subsequent STIs over the 2year observation period.

Summary of Intervention Findings
Alcohol venue-based HIV prevention interventions demonstrate a mixed pattern of results. Social influence interventions, particularly the POL model, appear effective in U.S. gay bars, including bars in small and large cities. What these venues have in com mon are closeknit social networks within which community members know and often trust each other. Gay communities have few public places where people can meet and socialize. Although the social landscape is changing in gay communities (Simon Rosser et al. 2008), gay bars historically have been the focal point. Still, social influ ence models closely tied to the POL model did not work in U.K. gay bars, Indian wine shops, and Zimbabwean beer halls. Understanding the charac teristics of social networks and environ ments that account for the effects of social influence interventions will determine the ultimate utility of these approaches.
The structural interventions reviewed here demonstrated promis ing outcomes. Enhancing STI and sexual health services through venue based programming increased hepati tis vaccination and HIV testing in the U.K. and reduced STIs in women involved in sex work in China and men attending gay bars in New York City. Most promising are the additive effects of social influence and manager training to improve sexworker health in the Philippines. The pattern of results from these few trials suggest that interventions that simultaneously target individual, social, and struc tural risk factors may hold the great est promise for alcohol venue-based HIV prevention.

Advancing Alcohol Venue-Based HIV Prevention
Models of HIV risk reduction focused on the individual may be insufficient for reducing alcoholrelated HIV risks because they do not address social, structural/environmental, and contex tual influences on behavior. Individual level models rarely achieve sustained behavior change due to unaltered risk environments, the potency of peer pressure, social reinforcements for maintaining risk behaviors, and the interaction between alcohol use and alcohol environments in promoting sexual risks. Interventions that address social influences on behavior, such as social norms and interpersonal contin gencies of reinforcement (such as in the POL model), will help support initial behavior changes for potentially long durations. In addition, changes to the physical environment, including poli cies that impact behavior, also can maintain riskreducing practices. Interventions that integrate individual, interpersonal, and environmental levels of change will likely prove most effec tive in reducing alcoholrelated HIV risks.
Individuallevel intervention com ponents aim to influence motivation and build problemsolving skills, con dom use, and sexual negotiation skills. Individual skillsbased HIV prevention interventions have proven effective at reducing HIV risk behav iors among drinkers, albeit for short periods of time (Kalichman et al. 2007). Individual skillsbuilding interventions also can include com munication skills training geared toward influencing social interactions and social networks within drinking environments. Finally, environmental and policy interventions can support the individual and social influence changes by creating more protective environments. Although there are few structural interventions for sexual risk behavior, policies that regulate drink ing age, maintain safety standards of drinking environments, offer health services to sex workers, and provide universal access to STI treatment will likely have a significant impact on HIV risks.
Multilevel alcohol venue-based interventions are feasible for imple mentation in alcoholserving estab lishments. Weir and colleagues (2008) describe environmental com ponents that fit well within the parameters of multilevel interven tions. Social cues and prompts can be placed in drinking environments by using posters to communicate pre vention messages. Condoms also can be made accessible in venues using dispensers and condom machines with signage. Weir and colleagues (2008) suggest using outreach work ers with brief surveys to help engage patrons and raise awareness. Finally, events that support HIV prevention, such as drama and music events, can be implemented in drinking places and include onsite HIV testing and STI screening. Structural changes in the drinking environment will both foster and sustain behavior change that occurs with intensive interven tions delivered at individual and social levels. As suggested by Morisky and colleagues (2006), structural changes can be implemented gradual ly and in synch with the current envi ronment and policies.
HIV prevention behaviors can be adopted, accepted, and become nor mative within social networks (Kelly et al. 2006;Latkin et al. 2004), and these processes can occur within drinking environments. A subset of influential community members can encourage behavior change through informal social interactions in exist ing relationships within drinking places. Concepts derived from net workbased interventions can be applied though multilevel approaches and provide a mechanism for altering social environments to shape, sup port, and reinforce behavior change.
Interventions can be designed to use existing social networks in drinking places. Peerdriven interventions, for example, that have been successful in U.S. gay bars and among injection drug using populations can be enhanced by having community health and outreach workers deliver prevention messages and resources, such as condoms. Drinking environ ments can provide venues for chain recruitment of successive waves of peers. At the structural level, drinking environments can post prevention messages that encourage conversa tion. Venue owners can be enlisted to help shape the house rules, enforce drinking laws, provide condoms, invite health department screenings and onsite testing, and promote the health of their staff as well as clients.
Historically, HIV prevention sci ence has examined intervention com ponents one level at a time. Results from singlelevel interventions have been discouraging, whereas interven tions implemented at multiple levels have been more encouraging. Thus, it would appear that the most promis ing approaches to effective alcohol venue-based interventions are those that are multilevel and sustained over long periods of time. Multilevel HIV prevention interventions in drinking venues therefore warrant further investigation. ■

Financial Disclosure
The author declares that he has no competing financial interests.